GQ Corner
Q. Claimant settles his third party claim for $50,000.00, and now we have a “holiday” for that amount. Shortly after the settlement, Claimant filed her application for SIBs for the first quarter. How do I handle this?
A. You need to review the merit of the quarter and raise a dispute if the IW has not demonstrated entitlement. The lien holiday should only apply against benefits as they accrue and if the IW does not do what is needed to qualify for SIBS he should not get the benefit of discharging the holiday balance.
If the IW is entitled to SIBs, send a PLN-9 and file a PLN-11 indicating that SIBS are being suspended until this subrogation lien is exhausted.
Q. I have an injured worker who submits a meal reimbursement request for each and every medical appointment, regardless of the time of the appointment. Am I required to reimburse each request?
A. Not necessarily. Rule 134.110 states that, in order for reimbursement to occur, the medical treatment for the compensable injury must not be reasonably available within 30 miles from the injured employee’s residence. Subsection (4) states that when an injured employee’s travel reasonably includes food, then the insurance carrier shall reimburse for the actual expenses (of the injured employee only) not to exceed the current rate for state employees. In reviewing the request for reimbursement, you can review whether the length of the travel and the timing of the appointment would reasonably require a meal.
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